1. Joint Manipulations

2. The Evidence up to 2004
Assendelft et al. Cochrane Database Syst Rev. 2004
Systematic Review of RCT’s that evaluated spinal manipulative therapy for patients with low back pain were researched to update effectiveness of spinal manipulation in comparison to other therapies

3. Comparison Treatments
Classified in seven treatment categories:
Sham
Conventional general practitioner care
Analgesics
Physical Therapy
Exercises
Backschool
Therapies judged to be ineffective or even harmful (traction, corset, bedrest, homecare, topical gel, no treatment and diathermy)

4. Outcomes
Manipulation had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises or back school
For patients with acute low back pain, manipulation was superior only to sham therapy, or therapies judged to be ineffective or even harmful

5. Clinical Prediction Rule for Spinal Manipulation
In 2004 Childs et al developed a clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation ).
Purpose: determine the likelihood of patients responding with a 50% or greater reduction in disability following a program of spinal manipulation and exercise.
Childs, J. et. al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of internal medicine Vol. 141, No. 12, 2004

6. Five criteria were identified
Duration of current episode less than 16 days
No symptoms distal to the knee
Lumbar spine hypomobility at any level
FABQ work subscale score <19 points
Hip internal rotation with 1 or both hips having at least 35 degrees of internal rotation

7. Outcome When at least 4 of the five criteria were met: +LR = 13.2.
When only 1 or 2 of the criteria were met: - LR = .10

8. Which patients do not benefit from spine manipulation?
Longer symptom duration
Presence of symptoms distal to the back
Absence of hypomobility in the lumbar spine
Negative SI provocation tests
Reduced hip rotation ROM

9. Better outcomes with manipulation
A case control study by Fritz showed that patients receiving thrust manipulation had:
Fewer treatment sessions,
Shorter length of stay
Lower cost in physical therapy than patients receiving non-thrust manipulation.
Fritz JM, Brennan GP, Leaman H. Does the evidence for spinal manipulation translate into better outcomes in routine clinical care for patients with occupational low back pain? A case control study. Spine Journal 2006

10. So why the reluctance to manipulate in the face of overwhelming evidence?
Two main reasons:
Not educated well enough
Fear of harm

11. Complications
Serious complications due to L spine manipulations are extremely rare. It is estimated at 1 per 100 million lumbar manipulations results in a cauda equina lesion
In comparison, each year 7600 people die in the US alone as a result of taking NSAIDs
Another people require hospitalization as a result of taking NSAIDs

12. Safety and effectiveness
Not dependent on:
Type of practioner
Technique used
Years of experience

13. Cervical Spine CPR Symptom duration < 38 days
Expectation that manipulation will help
Difference in C rotation side to side >10 degrees
Pain with PA spring testing mid C spine
If 3 out of 4 attributes present, the probability of experiencing a positive outcome improved to 90%
Positive LR 13.5
Puentedura E et al. Development of a clinical prediction rule to identify paitients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. JOSPT 2012 Vol 42 No 7

14. Six predictors were developed Symptom duration < 30 days
CPR for treatment of a subgroup of patients with neck pain with T spine manipulation, exercise and education Cleland et al. Physical Therapy 2007
Six predictors were developed
Symptom duration < 30 days
No symptoms distal to the shoulder
Looking up does not aggravate the symptoms
FABQPA <12
Decreased upper thoracic kyphosis
Cervical extension <30 days
If 3 of 6 present: 86% success rate with manipulation

15. The audible pop
The audible pop is the sound resulting from the release of nitrogen gas in the joint cavity when a sufficiently large negative pressure is created

16. The audible pop
Flynn (2006) concluded that a perceived audible pop may not relate to improved outcomes for patients with non radicular low back pain, either immediate or at long term follow up

17. Does spinal manipulation cavitate the targeted joint?
Beffa (2004) found that manipulation was not associated with the targeted joint frequently enough to make a statistical difference

18. Accuracy
KimRoss (2004) found that manipulations are accurate about half the time In the L spine the average error was at least one vertebra away from the targeted level. (5.29 cm) In the T spine the average error was 3.5 cm Most procedures were associated with multiple cavitations, including the targeted level

19. Mechanical Psychological Neurological
Effects of Manipulation
Mechanical Psychological Neurological

20. Mechanical Effect of Manipulation
Restore positional faults
Breaking up intra articular adhesions
Release of meniscoid inclusions

21. Positional Fault Talus
The underlying cause appears to be a joint dysfunction of the subtalar joint. The positional fault is easily identifiable. It is likely of a rotatory kind, not translatoric, which is hard to visualize on 2 dimensional MRI

22. Stress reaction Talus
55 yr old female IM triathlete. Injury occurred after 18 mile run. Sudden onset of pain. Not able to run. Walking with significant limp

23. Neurological Effect of Manipulation
Mechanical force used during manipulation has a direct effect on the central nervous system, creating positive neurophysiological responses resulting in a reduced overall central sensitization

24. Neurological Effect of Manipulation
The effects of manipulation are beyond biomechanical changes only; however, in the current literature, there is no clear explanation for some of the effects of manipulation Sillevis et al. Immediate effects of thoracic spine thrust manipulation JMMT 2010

25. Effect on autonomous nervous system
Thoracic spine manipulation showed favorable outcomes in the treatment of a patient with UE complex regional pain syndrome
T spine manipulation resulted in a decrease in dystrophic and allodynic symptoms
Menck et al. Thoracic spine dysfunction in upper extremity complex regional pain syndrome type I. JOSPT 2000;30(7)

26. Cervical Spine Manipulation for Pediatric Population

27. Anatomical Considerations

28. Biomechanical considerations

29. Biomechanical considerations

31. Informed Consent You have to obtain informed consent
Verbal consent is recommended and document as such in your notes
Informed consent differs from state to state, which makes it difficult to specify how this needs to be worded

32. Our recommendation
“I would like to perform a “quick stretch” to your neck to improve the movement of a particular joint. You may sense a “popping” of the joint and may experience some local soreness due to the stretching procedure. Is it OK to perform this quick stretch?”

33. Component technique
In component technique we aim to create the barrier
Use basic principles of focusing, multiple components, and for “locking” contra rotation
Use secondary components to minimize amplitude of primary component or lever
Use compression
Identify the barrier, then back of a little
Hold the secondary components to maintain the barrier and amplify only the primary lever direction
Use good posture for security and effectiveness
When ready, focus forces, and engage the barrier

34. Posture and Manipulation
Conscious considered use of operator posture helps control:
Depth of forces
Direction of technique
Amplitude of levers
Power of the procedure
Sensitivity of hold
It improves the ability to focus the forces to a specific target site
It helps improve safety, security, effectiveness and reduces fatigue

35. Posture and Manipulation
General rules
Use a wide base
Use your body to perform technique, keep your hands “fixed”
Use rhythm
Demonstrate control

36. Posture and manipulation
Keep your head up. Literally
Keep your knees slightly bent
Move with your hips, and have your hands follow
Keep your centre of gravity low
Visualize the procedure
Keep the objective in mind
Play with the tissues
Mini thrusts

37. Keep your head up Keeps the spine straight
The straighter the spine, the more force directed into the patient, not the therapist
Avoids too close proximity
Brings elbows close to side for improved control

38. Keep knees slightly bent
Sharper impact possible
Less flexion in your spine
Subtle changes in direction can be accommodated
Less bending in the PT spine

39. Move your hips, with hands following
Easier acceleration
Hands are less uncomfortable for the patient when held steady
Proprioceptive palpation with operator body
Hands follow, allowing for maintenance of local control

40. Keep center of gravity low
Better balance
Easier changes in direction
Better transmission of force
Less therapist muscle stress

41. Visualize the procedure
How is your posture?
Are you using max efficiency?
Do you understand the principle of the procedure?
What would your posture look like in the mirror?

42. Keep the objective in mind
Is another way better?
Are you struggling with the wrong aspects?
Is control of the structures a problem?
Is another way possibly better?

43. Play with the tissues
Constructive fiddling is often useful to find the optimal direction/path of manipulation
Keep it moving. If you hold it still you only have about a 2 second window to perform the technique
Tissue reaction is the best guide, keep testing and assessing the responses
Less mistakes if you ask the tissues

44. Mini thrusts Prepare the tissues for final thrust
If you use only one thrust, you have a 25% chance of a good technique. Using mini thrusts significantly increases your chances of a good technique
Tissue anger will warn you off with mini thrusts
Barriers often ease without a more major method
Easier to get to the motion barrier with mini thrusts

45. In thrust techniques Usually one leg forward, one back
The thrusting hand is on the side of the rear leg
The rear heel is slightly raised
Keep your back straight
Brief isometric contraction of the abdomen

46. Focusing (isolate) to the segment
Focus to the joint using one or more vectors of compression, creating local tissue tension
Build the barrier
Once you have identified the barrier, back off a little
Use posture for security and effectiveness
When ready, focus your forces, and engage the barrier
Hold the secondary components to maintain the barrier and amplify only the primary lever direction

47. How can we focus without locking?
Use several components
Control the part being worked accurately
Direct forces according to anatomical principles
Be highly aware of palpatory cues
Learn how tissues respond to varied forces
Keep an open mind to the varied possibilities

48. Basic routine to build barrier using multiple components
Focus to the segment
Test the primary lever amplitude at the segment
Add some of the 1st chosen secondary lever
Retest the primary lever:
If the endfeel is not good, add some of the 2nd chosen secondary lever
Retest the primary lever
If the endfeel is still not good:
Add some of the 3rd chosen secondary lever
Retest the primary lever amplitude
At optimum barrier point, thrust in primary lever - without losing the other components